F.

Family History The client in the genogram depicted in the accompanying figure has hypertension (HTN) on his maternal side; it was the cause of death of the clients grandparents. Hypertension is inherited by the clients mother. On the clients paternal side are insulin dependent Diabetes mellitus (IDDM also known as Type 1 diabetes) and Chronic kidney disease (CKD). Last 2008, the clients father died due to these health problems. The clients sister had Pregnancy Induced Hypertension (PIH) while the clients brother is alive and well (A/W). It was shown that the patient is now has insulin dependent Diabetes mellitus (IDDM also known as Type 1 diabetes) and Chronic kidney disease which is the same health problem the patients father had.
G. Socio-Economic History

Family Member

Occupation

Monthly Income

R.M.S.A (pts Mother)

Retired

2,500 dollars

R.M.S.A is 75 years old, a retired employee in a department store in the United States of America and is the mother of the patient. R.M.S.A is the only provider because the clients father died last 2008. R.M.S.As monthly income is 2500 dollars or in Philippine money, more or less 115,000 pesos, 1500 dollars from the retirement benefit and 1000 dollars from the Social Security System or SSS which is a government institution. The client said that it is not enough to provide for their daily needs due to a lot of expenses, especially now that the client is hospitalized.

H. Psychosocial Assessment Patients Age: 46 yrs. Old Developmental Stage: Middle Adulthood Developmental Crisis: Generativity vs. Stagnation Developmental Virtue: Care Developmental Task: Being creative and productive; establishing the next generation In Erik Eriksons Psychosocial Development theory, ages 40 to 65 years old or the age of middle adulthood are more likely to have a crisis of Generativity vs. stagnation. During this period according to Erik Erickson, most adults are preoccupied with raising a family, and establishing themselves in their vocation or career. Some may find themselves in position of greater influence in society, such as in government. Adults develop a concern for the welfare of the future or younger generations, and the need to pass on or leave a legacy regarding what they have learned. This psychosocial need for generativity may take the form of parenting, mentoring, teaching, or engaging in sociocivic work. The patient seems to have a meaningful attachment to his family especially to his mother. The patients relatives visit him as often as they can, to show them how much they care and love him. The patient is a graduate of Information Technology (IT) and is currently not working because of a personal problem. The patient has no wife and kids of his own, but he has his niece and nephews that he loves very much. The patient always gives advices and tells them stories about his experiences in his life. On this stage most adults are preoccupied with raising a family, but the patient wasnt able to achieve this. The patient lives with his mother and treats his nephews and niece as his own children. The patient wants to practice his vocation but he cant because of his current health problem but despite of it he wants to help his family and make himself productive in his own simple way.

I.

Functional Assessment

J. Review of Systems and Physical Examination SYSTEM 1. General R.O.S Wala pa naman pagbabago, pero feeling y y y P.E Awake and conscious Ambulatory with minimal assistance With minimal

ko medyo pumayat ako, kasi hndi ako masyado kumakain

y y

y y 2. Integument Eto medyo dry ang balat ko Skin: y

movement T= 36 C RR= 12 cpm, regular, bilateral chest expansion PR= 96, 1+ BP= 120/80 mmHg

y y y Okay naman, wala naman nagiba, ganun pa din sa dati. y Hair: y y y

(+)Dry skin on both upper and lower extremities Fair skin (-)hyperpigmentation (-) maculopopular rashes Warm to touch Color: Black (+) Normal hair distribution (-) Presence of parasites

Nails: y Round, hard nails with pink nail beds y Capillary refill is < 3 seconds Hindi naman masakit ang ulo ko ngayon and I havent experience any head injuries so far y y y y Smooth, Symmetrical, firm (-) Lesions on the scalp Normocephalic Temporomandibular joint felt bilaterally with full ROM

3. Head

4. Eyes Hindi na ako nakakakita sa right eye ko I dont wear eye glasses or y y Round iris Bulbar conjunctiva clear with tiny vessels visible Nontender lacrimal apparatus

contact lense kahit dati pa

5. Ears

Hindi naman sumasakit ang tenga ko Cotton Buds ang gamit ko panlinis

y y y

Passed whisper test (-) tenderness (-) discharge on external ear

6. Nose and Sinuses

Wala naman ako sipon ngayon

y y y y

y 7. Mouth and Throat okay naman, hindi naman masakit o kakaiba y y y y y y y

(-) nasal flaring (-) nasal discharge (-) lesion in turbinates and septum Pink and moist mucosa with no lesions Sinuses clear upon illumination

Pharyngeal tonsils not inflamed Moist lips (-) lesions on lips (-) hoarseness (+) full ROM (-) cervical lymph node enlargement Smooth, firm and non-tender thyroid (-) dimpling (-) discoloration (-) axillary lymph node enlargement Flat, pale brown areola (-) cough (-)Crepitus (-)wheezing Symmetrical thoracic

8. Neck Hindi naman masakit pagginagalaw ko and aking neck 9. Breast and Axilla Pareho lang naman katulad dati, hindi naman masakit 10. Respiratory wala naman ako ubo ngayon

y y y y

y y y y

I have no history of any respiratory related illness 11. Cardiac Hindi naman ako nahihirapan huminga 12. Gastrointestinal minsan wala ako gana kumain hindi pa ako nakakapagba was ngayon 13. Urinary Eto may Chronic Kidney disease ako, hindi pa ako nakakaihi ngayon eh 14. Genitalia okay naman, wala naman problema 15. Peripheral Vascular Wala din naman problema

expansion RR= 12 cpm, regular, bilateral chest expansion.

y y y

PR= 96, 1+ (+) apical pulse felt at 5th ICS LMC line Identical apical and radial pulse

y y y y

(-) rashes Round, flabby abdomen (-) mass (+) slightly distended abdomen Urine color: amber yellow (+) bladder distention

y y

y y

(+)rashes No lesions and inflammations noted

y y y y

(-)jaundice (-) Pallor (-) lesions Capillary refill <3 seconds (-) Weakness (-) full ROM on lower extremities (-)full ROM on upper extremities Muscle strength grading: no. 2 or poor ROM

16. Musculoskeletal Hindi ko pa masyado nagagalaw ng maayos yung right arm and leg ko, kasi nastroke ako last week

y y y y

17. Neurologic

Na-stroke ako last week lang

y y

18. Hematologic 19. Endocrine

Hindi naman ako anemic hindi naman ako pawisin na tao

y y y y

Oriented to time, place and person Responds to questions and statements appropriately (-) bruising (-)bleeding (-) excessive sweating (+) heat and cold tolerance

20. Psychiatric

ahh, hndi naman pa naman ako nagiging makalimutin kahit tumatanda na ako

NO P.E.

III.
Diabetes Mellitus

PATHOPHYSIOLOGY

The pathophysiology of diabetes mellitus (All types) is related to the hormone insulin, which is secreted by the beta cells of the pancreas. This hormone is responsible for maintaining glucose level in the blood. It allows the body cells to use glucose as a main energy source. However, in a diabetic person, due to abnormal insulin metabolism, the body cells and tissues do not make use of glucose from the blood, resulting in an elevated level of blood glucose or hyperglycemia. Over a period of time, high glucose level in the bloodstream can lead to severe complications, such as eye disorders, cardiovascular diseases, kidney damage and nerve problems. In Type 1 diabetes, the pancreas cannot synthesize enough amount of insulin hormone as required by the body. The pathophysiology of Type 1 diabetes mellitus suggests that it is an autoimmune disease, in which the body's own immune system generates secretion of substances that attack the beta cells of the pancreas. Consequently, the pancreas secretes little or no insulin. Type 1 diabetes is more common among children and young adults (around 20 years). Since it is common among young individuals and insulin hormone is used for treatment, Type 1 diabetes is also referred to as Insulin Dependent Dabetes Mellitus (IDDM) or Juvenile Diabetes.

Cerebrovascular accident
Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting longer than 24 hours. Stroke are either ischemic, caused by partial or complete occlusions of a cerebral blood vessel by cerebral thrombosis or embolism or hemorrhage. Hemorrhage may occur outside the dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance itself (intracerebral). Risk factors for stroke include transient ischemic attacks (TIAs) warning sign of impending stroke hypertension, arteriosclerosis, heart disease, elevated cholesterol, diabetes mellitus, obesity, carotid stenosis, polycythemia, hormonal use, I.V., drug use, arrhythmias, and cigarette smoking. Complications of stroke include aspiration pneumonia, dysphagia, constractures, deep vein thrombosis, pulmonary embolism, depression and brain stem herniation. An ischemic stroke may be caused by a thrombosis, embolism, or lacunar infarct. Blockage of a single artery can often be compensated for by other arteries in the blood vessel network, call collaterals. Artherosclerosis (hardening of the arteries), other damage to arteries, and natural variations in the collateral network can prevent the collateral system from compensating fully. The result is a loss of perfusion, or blood supply, to an area of the brain (ischemia). Chronic Kidney Disease Approximately 1 million nephrons are present in each kidney, each contributing to the total GFR. Regardless of the etiology of renal injury, with progressive destruction of nephrons, the kidney has an innate ability to maintain GFR by hyperfiltration and compensatory hypertrophy of the remaining healthy nephrons. This nephron adaptability allows for continued normal clearance of plasma solutes so that substances such as urea and creatinine start to show significant increases in plasma levels only after total GFR has decreased to 50%, when the renal reserve has been exhausted. The plasma creatinine value will approximately double with a 50% reduction in GFR. A rise in plasma creatinine from a baseline value of 0.6 mg/dL to 1.2 mg/dL in a patient, although still within the reference range, actually represents a loss of 50% of functioning nephron mass. The residual nephron hyperfiltration and hypertrophy, although beneficial, has been hypothesized to represent a major cause of progressive renal dysfunction. This is believed to occur because of increased glomerular capillary pressure, which damages the capillaries and leads initially to focal and segmental glomerulosclerosis and eventually to global glomerulosclerosis

IV. Procedure/ Date

LABORATORY STUDIES AND DIAGNOSTICS Indications Normal Actual Nursing Values/Findi Findings/ Responsibilitie ngs Interpretation s y WBC y 5.0-10.0 y 4.6-6.2
y y 9.3x109/L (Normal) 4.4x1012/L (Normal)

The complete blood y RBC Hematology count (CBC) is a screening test, (January used to diagnose y Hemoglobin 27, 2011) and manage numerous diseases. It can y Hematocrit reflect problems with fluid volume (such as Differential dehydration) or loss Count of blood. It can show abnormalities in the production, y Segmenters life span, and destruction of blood cells. It can reflect y Lymphocytes acute or chronic infection, allergies, and problems with y Platelet clotting. Count This test is used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, State of hydration and dehydration, Polycythemia, Hemolytic disease of the newborn, to manage

y 123153G/L y 0.370.48%

127g/c
(Normal)

 Monitor the condition of the patient  Monitor vital signs

38% (Above normal)

y 0.55-0.65 y 0.25-0.35

y 0.83 (Above normal) y 0.17 (Below normal) y 249x109/L (Normal)

y 150-450x 109/L

chemotherapy decisions.

y January 27, 2011 y y y y y y

Blood Urea Nitrogen Creatinine Potassium Cholesterol Triglycerides HDL LDL

y 7.0-23.0 mgs/dl y 0.51.7mgs/dl y 3.6 mmol/L y 150200mg/dl y 44148mg/dl y 26.63 mgs/dl y <150

y 30.6 mgs/dl  Monitor the (Above condition normal) of the y 5.4 mg/dl patient (Above  Monitor normal) vital signs y 3.61mmol/L (Normal) y 190.3 mg/dl (Normal) y 65.8 mg/dl (Normal) y 35.7 mg/dl ( Above normal) y 141.4mgs/d l

V.

MEDICAL-SURGICAL MANAGEMENT 1. Procedures Procedure and Indication Date

Nursing Responsibilities (pre, intra, post)

Peritoneal dialysis

Started Last January 24, 2011

-Primarily used is to provide an artificial replacement for lost kidney function in people with renal failure.

-Monitor Vital signs especially the BP of the Patient

-Pt with Chronic or acute Kidney Disease

2. Pharmacotherapeutics/medicines Generic Name (Brand name) Classification Indication(Client Specific) Dosage Frequency -Hypertension -80mg, IV -Ever 6 hours (q6) Nursing Responsibilities/Implication (pre, Intra, Post) -Observed 10Rs in giving medications to the patient -ensuring it is prescribed before administration and recording patient observations for any adverse effects, a rise in heart rate can be fairly common -Asses pt for any allergy to Furosemide -Monitor Vital sign. -Readjust dosage gradually as BP responds -Give early in the day so that increased urination will not disturb sleep -Do not exposed to light, which may discolor solution -discard diluted solution after 24 hours. -Measure and record weight to monitor fluid changes. -Arrange to monitor serum electrolytes, hydration, liver and renal function. -Arrange for potassium-rich diet or supplemental potassium as needed.

Furosemide (Lasix) Loop Diuretic

Calcium Carbonate (Apo-Cal) Antacid

-Symptomatic relief of upset stomach associated with hyperacidity; -Dietary supplement when calcium intake

-Observed 10Rs in giving medications to the patient -Assess pt for any allergy to calcium -Monitor Vital signs -Do not administer oral drugs within 1-2 hour of antacid

is inadequate -1 tablet, P.O -TID

administration. -Have patient chew antacid tablets thoroughly before swallowing; following with a glass of water or milk -Give calcium carbonate antacid 1 and 3 hours after meals and at bedtime

Acetylcysteine (Mucomyst) Mucolytic

-Mucolytic adjuvant therapy for abnormal, viscid, or inspissated mucus secretions. -200mg sachet, PO -Every 12 hours (q12)

- Observed 10Rs in giving medications to the patient - assess pt for any allergy to Acetylcysteine. -Monitor Vital signs -Inform patient that he may experience these side effects: increased productive cough, nausea, GI upset. -Instruct patient to report difficulty of breathing or nausea

Ferrous Sulfate (Feosol) Iron Preparation

-Prevention and treatment of iron deficiency anemia -1 tablet, PO -OD

- Observed 10Rs in giving medications to the patient - assess pt for any allergy to ingredient, sulfite; hemochromatosis, hemosiderosis, hemolytic anemia; normal iron balance. -Monitor Vital signs -Give drug with meals -Warn patient that stool may be dark or green -Inform patient that he may experience these side effects: GI upset, nausea, vomiting, diarrhea or constipation. -Instruct patient to report GI upset, lethargy, rapid

respirations and constipation

Aliskiren (Tekturna) Antihypertensive

-Treatment of hypertension, alone or with other antihypertensives -150 mg, PO -OD

- Observed 10Rs in giving medications to the patient - assess pt for any allergy to any content of the drug. - Monitor Vital signs - Monitor serum potassium level periodically - Monitor Patient also receiving furosemide for possible loss of diuretic effects. Continue other hypertensive drug as needed to control blood pressure -Advice patient to take drug once a day, at about the same time each day. If a dose is miss, take it as soon as remembered; then resume the usual schedule the next day. Do not make up missed doses. Do not take more than one dose each day -Store the drug at a room temperature in a dry place. -Inform the patient that he may experience low blood pressure if also taking diuretics, if become dehydrated, or if the patient has dialysis treatments. -Instruct patient to report difficulty breathing; swelling of face, lips, or tongue; dizziness or light headedness -Instruct patient to report

difficulty breathing; swelling of face, lips, or tongue; dizziness or light headedness.

Tramadol (Tramal) Analgesic

-For patients with

moderate to moderately severe chronic pain not requiring rapid onset of analgesic effect.

-50mg,PO -Every 8 hours (q8)

- Observed 10Rs in giving medications to the patient - assess pt for any allergy to any content of the drug. - Monitor Vital signs -While not nearly as dangerous a respiratory depressant as other opioids or opiates, at high doses, this may be a consideration. -Tramadol is metabolized in the liver. Nurses are cautioned to doublecheck for meds that inhibhit liver function, or watch for adminstration on hepatic compromised patients. -Tramadol lowers the seizure threshold. It also synergizes with SSRI's and tricyclics, and may have a stronger effect on epileptics. Ergo, seizure warning.

Renogen (Epogen ) Hematopoietic

-Treatment of anemia associated w/ chronic renal failure (CRF) -4000u, SQ -once a week

-Observed 10Rs in giving medications to the patient - assess pt for any allergy to any content of the drug. - Monitor Vital signs
-Monitor renal studies: urinalysis, protein, blood, BUN,

creatinine; input-output ratio; report drop in output to <50mL/hr. -Assess for CNS symptoms: coldness, sweating, pain in long bones -Assess CV status: BP and during treatment; hypertension may occur rapidly ;leading to hypertension encephalopathy, antihypertensives may be needed -Monitor serum iron levels, ferritin, transferring levels; iron therapy may be needed to prevent recurring anemia -Monitor blood studies: BUN, creatinine, uric acid, platelets, WBC, phosphorus, potassium, bleeding time; Hct, Hgb, RBCs,reticulocytes should be checked in chronic renal failure

VI.
CUES

NURSING CARE PLAN

OBJECTIVES OF CARE PLAN OF INTERVENTION RATIONALE EVALUATION SCHEME

NURSING DIAGNOSIS

Subjective: Hindi pa ako nakakaihi simula

A1: Impaired Urinary

P1: Within the shift, the pt will able

- Will Establish rapport with the patient

G1: Reassess the urinary

kaninang 12 am Objectives: -Received pt on bed in a semi-fowlers position -Conscious, coherent and communicati ve, oriented to time, place and person -with O2 via nasal cannula @ 2Lpm -with IVF of #8 D5 0.3 Nacl x KVO hooked @ left metacarpal vein received @ 290 cc level running at a rate of 3 gtts/min., intact and infusing well -with Tenckhoff catheter connected

Elimination related to incompetent bladder distention secondary to chronic kidney disease A2: Risk for infection related to retention of urine or induction of urinary catheter

able to void 20 to 30 cc per hour.

-Will monitor and record vital signs -Will assess the patients abdomen -Will keep the linens clean and wrinkle free -Will advice the patient to ask all visitors and personnel to wash their hands before approaching him -Will advice the patient to limit visitors -Will instruct the patient and the family members the signs and symptoms of infection -Will assess the patient on the clinical manifestation of infection such as fever, through vital signs.

elimination of the patient G2: Reassess the patients learning related to the risk factors associated with the infection and precautions needed.

P2: Within the shift the pt will report the risk factors associated with infection and precautions needed.

@ patients umbilical area of the abdomen, potent for peritoneal dialysis -(+) slightly distended abdomen -with initial vital signs as of February 3, 2011, 4pm: Temp: 36C
PR: 96, 1+ RR: 12 cpm, regular, bilateral chest expansion. BP: 120/80 mmHg